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ATYPICAL PRESENTATION OF SCABIETIC URTICARIAL VASCULITIS
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
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M503 SUBCUTANEOUS ALLERGEN IMMUNOTHERAPY IN THE TREATMENT OF ATOPIC DERMATITIS A. Nanda*1, A. Wasan2, 1. Lewisville, TX; 2. McLean, VA Introduction: Atopic dermatitis has a wide variety of therapies, including topical moisturizers, topical corticosteroids, and biologics. However, there is still a debate regarding the efficacy of allergen immunotherapy in the treatment of atopic dermatitis. We report atopic dermatitis treated successfully with allergen immunotherapy. Case Description: A patient was referred to our practice for the treatment of severe atopic dermatitis. A 48-year old man presented with a history of severe atopic dermatitis since childhood. Previous therapies, including mid and high potency topical corticosteroids, as well as the calcineurin inhibitors, pimecrolimus and tacrolimus, were ineffective. He had also required multiple doses of systemic corticosteroids for exacerbations. Biologic therapy was not available. He had positive specific IgE and allergy skin testing to multiple inhaled allergens, including dust mite, weeds, trees, grasses, mold, cat, and dog. The IgE level was 10,000 IU/mL. His initial Scoring Atopic Dermatitis Index (SCORAD) was 79.4. He was started on subcutaneous allergen immunotherapy to these inhaled allergens, while his topical therapies remained the same. In one year, at maintenance therapy at 1:1 dilution (0.5 cc injections), patient reported significant benefit in symptoms, and SCORAD index decreased to 48.5. He did not require systemic systemic steroid therapy once he reached maintenance dose of immunotherapy. Discussion: Subcutaneous allergen immunotherapy can be an effective therapy for atopic dermatitis. This therapy can be used in conjunction with other treatments, including topical ones. Larger studies are required to further evaluate this therapy in atopic dermatitis.
M504 AN UNUSUAL RASH IN A PATIENT WITH PULMONARY EMBOLISM D. Munoz Mendoza*, S. Bahna, Shreveport, LA Introduction: Rashes are common and mostly benign but some may reflect serious disease. Case Description: A 54-year-old male presented 2 months after developing a pruritic, erythematous, generalized papular rash. It did not improve on amoxicillin, antihistamines, and topical corticosteroids. He developed acute SOB and chest CT revealed pulmonary embolism treated with anticoagulant (apixaban). However, the rash worsened and the patient was transferred to our hospital. On PE, the right arm was swollen, erythematous, warm, and tender, with few vesicles on the forearm (Fig). There were also multiple small vesicles on the back, upper chest, and face. There was no lymphadenopathy. Patient was started on clindamycin. Apixaban was switched to enoxaparin for possible drug reaction. CBC was normal except for eosinophilia 4090/mL. He had negative blood culture and normal CMP, troponin, and EKG. Ultrasound on right arm showed no DVT. Chest CT showed multiple hypodense fillings scattered throughout both lungs. Serology for HIV, Toxocara, Strongyloides, Coccidiodes, and Histoplasmosis were negative. The rash worsened with involvement of the left arm and face. Biopsy showed intracorneal/subcorneal bullae with marked eosinophilic infiltrate, but negative immunofluorescence studies, HSV, VZ, and acid fast bacilli. He developed dysphagia and esophageal biopsies revealed 20-30 eosinophils/HPF. Methylprednisolone 60 mg BID resulted in rapid improvement within 2 days in the skin and eosinophilia (20/mL). Laboratory tests were negative for eosinophilic granulomatosis with polyangiitis, mastocytosis, and myeloproliferative or lymphocytic hypereosinophilic disease. Discussion: The rash was considered eosinophilic cellulitis likely secondary to idiopathic hypereosinophilic syndrome.
Swelling of the arm with erythematous rash and few vesicles.
M505 ATYPICAL PRESENTATION OF SCABIETIC URTICARIAL VASCULITIS J. Hanna*, T. Bingemann, Rochester, NY Introduction: Pruritic rash with burrows is pathognomonic for scabies. Classic lesions are seen less frequently as the incidence has increased. Our patient presented with none of the classic findings of scabies and biopsy features consistent with urticarial vasculitis. Case Description: 75-year old male presented with a generalized urticarial eruption for 1 month that burned and itched, and was accompanied by post-inflammatory hyperpigmentation. No new medications had been started. No family members had similar symptoms. Multiple urticarial plaques were noted with post-inflammatory changes without burrows. Dermatographism was present. Skin biopsy showed dense perivascular and superficial interstitial infiltrate, leukocytoclasis, and smudged small vessel walls. No mites or eggs were identified. No eosinophilia was present. Autoimmune work up and complement were normal. Treatment with Colchicine, Dapsone, Prednisone, and Hydroxychloroquine led to initial improvement but then relapse. When he was not improving, we sent him to dermatology again and they did not recommend any changes. As medications were changed, lesions again improved and then worsened. He called complaining of persistent lesions. When he was seen at that point, he had developed typical features of scabies and was treated with topical Permethrin and oral Ivermectin and rash completely subsided. After he improved, he was tapered off Dapsone without recurrence of his symptoms. Discussion: Urticarial vasculitis is an uncommon presentation of scabies with frequently delayed diagnosis. This case serves as a reminder to reassess the diagnosis if the patient does not respond as expected to treatment and adds to the cases of scabies with atypical presentations.
M506 IATROGENIC SYSTEMIC ALLERGIC CONTACT DERMATITIS FROM CETIRIZINE AND LEVOCETIRIZINE D. Lei*, C. Guo, P. Greenberger, Chicago, IL Introduction: H1 antihistamines are frequently utilized in the management of dermatitis-associated pruritus; they may be overlooked and are rarely considered as an etiology for dermatitis. Case Description: A 76-year-old woman with a history of allergic rhinitis and hypertension was referred for one year of pruritic, erythematous papules/plaques scattered throughout the body, worse over sun-exposed areas. Prior dermatologic evaluation and biopsy were suggestive of allergic contact dermatitis. Patch testing was positive for fragrance mix, ethylenediamine, and balsam of peru. The patient
S131
M503 SUBCUTANEOUS ALLERGEN IMMUNOTHERAPY IN THE TREATMENT OF ATOPIC DERMATITIS A. Nanda*1, A. Wasan2, 1. Lewisville, TX; 2. McLean, VA Introduction: Atopic dermatitis has a wide variety of therapies, including topical moisturizers, topical corticosteroids, and biologics. However, there is still a debate regarding the efficacy of allergen immunotherapy in the treatment of atopic dermatitis. We report atopic dermatitis treated successfully with allergen immunotherapy. Case Description: A patient was referred to our practice for the treatment of severe atopic dermatitis. A 48-year old man presented with a history of severe atopic dermatitis since childhood. Previous therapies, including mid and high potency topical corticosteroids, as well as the calcineurin inhibitors, pimecrolimus and tacrolimus, were ineffective. He had also required multiple doses of systemic corticosteroids for exacerbations. Biologic therapy was not available. He had positive specific IgE and allergy skin testing to multiple inhaled allergens, including dust mite, weeds, trees, grasses, mold, cat, and dog. The IgE level was 10,000 IU/mL. His initial Scoring Atopic Dermatitis Index (SCORAD) was 79.4. He was started on subcutaneous allergen immunotherapy to these inhaled allergens, while his topical therapies remained the same. In one year, at maintenance therapy at 1:1 dilution (0.5 cc injections), patient reported significant benefit in symptoms, and SCORAD index decreased to 48.5. He did not require systemic systemic steroid therapy once he reached maintenance dose of immunotherapy. Discussion: Subcutaneous allergen immunotherapy can be an effective therapy for atopic dermatitis. This therapy can be used in conjunction with other treatments, including topical ones. Larger studies are required to further evaluate this therapy in atopic dermatitis.
M504 AN UNUSUAL RASH IN A PATIENT WITH PULMONARY EMBOLISM D. Munoz Mendoza*, S. Bahna, Shreveport, LA Introduction: Rashes are common and mostly benign but some may reflect serious disease. Case Description: A 54-year-old male presented 2 months after developing a pruritic, erythematous, generalized papular rash. It did not improve on amoxicillin, antihistamines, and topical corticosteroids. He developed acute SOB and chest CT revealed pulmonary embolism treated with anticoagulant (apixaban). However, the rash worsened and the patient was transferred to our hospital. On PE, the right arm was swollen, erythematous, warm, and tender, with few vesicles on the forearm (Fig). There were also multiple small vesicles on the back, upper chest, and face. There was no lymphadenopathy. Patient was started on clindamycin. Apixaban was switched to enoxaparin for possible drug reaction. CBC was normal except for eosinophilia 4090/mL. He had negative blood culture and normal CMP, troponin, and EKG. Ultrasound on right arm showed no DVT. Chest CT showed multiple hypodense fillings scattered throughout both lungs. Serology for HIV, Toxocara, Strongyloides, Coccidiodes, and Histoplasmosis were negative. The rash worsened with involvement of the left arm and face. Biopsy showed intracorneal/subcorneal bullae with marked eosinophilic infiltrate, but negative immunofluorescence studies, HSV, VZ, and acid fast bacilli. He developed dysphagia and esophageal biopsies revealed 20-30 eosinophils/HPF. Methylprednisolone 60 mg BID resulted in rapid improvement within 2 days in the skin and eosinophilia (20/mL). Laboratory tests were negative for eosinophilic granulomatosis with polyangiitis, mastocytosis, and myeloproliferative or lymphocytic hypereosinophilic disease. Discussion: The rash was considered eosinophilic cellulitis likely secondary to idiopathic hypereosinophilic syndrome.
Swelling of the arm with erythematous rash and few vesicles.
M505 ATYPICAL PRESENTATION OF SCABIETIC URTICARIAL VASCULITIS J. Hanna*, T. Bingemann, Rochester, NY Introduction: Pruritic rash with burrows is pathognomonic for scabies. Classic lesions are seen less frequently as the incidence has increased. Our patient presented with none of the classic findings of scabies and biopsy features consistent with urticarial vasculitis. Case Description: 75-year old male presented with a generalized urticarial eruption for 1 month that burned and itched, and was accompanied by post-inflammatory hyperpigmentation. No new medications had been started. No family members had similar symptoms. Multiple urticarial plaques were noted with post-inflammatory changes without burrows. Dermatographism was present. Skin biopsy showed dense perivascular and superficial interstitial infiltrate, leukocytoclasis, and smudged small vessel walls. No mites or eggs were identified. No eosinophilia was present. Autoimmune work up and complement were normal. Treatment with Colchicine, Dapsone, Prednisone, and Hydroxychloroquine led to initial improvement but then relapse. When he was not improving, we sent him to dermatology again and they did not recommend any changes. As medications were changed, lesions again improved and then worsened. He called complaining of persistent lesions. When he was seen at that point, he had developed typical features of scabies and was treated with topical Permethrin and oral Ivermectin and rash completely subsided. After he improved, he was tapered off Dapsone without recurrence of his symptoms. Discussion: Urticarial vasculitis is an uncommon presentation of scabies with frequently delayed diagnosis. This case serves as a reminder to reassess the diagnosis if the patient does not respond as expected to treatment and adds to the cases of scabies with atypical presentations.
M506 IATROGENIC SYSTEMIC ALLERGIC CONTACT DERMATITIS FROM CETIRIZINE AND LEVOCETIRIZINE D. Lei*, C. Guo, P. Greenberger, Chicago, IL Introduction: H1 antihistamines are frequently utilized in the management of dermatitis-associated pruritus; they may be overlooked and are rarely considered as an etiology for dermatitis. Case Description: A 76-year-old woman with a history of allergic rhinitis and hypertension was referred for one year of pruritic, erythematous papules/plaques scattered throughout the body, worse over sun-exposed areas. Prior dermatologic evaluation and biopsy were suggestive of allergic contact dermatitis. Patch testing was positive for fragrance mix, ethylenediamine, and balsam of peru. The patient